Comparative study on the establishment efficacy of four types of animal models of rectovaginal fistula in rabbits.

Various surgical methods have so far been developed for treating rectovaginal fistula (RVF), each with its own advantages and disadvantages. The lack of standardized animal models of RVF is a major reason for the failure to establish a unified and effective surgical method for the treatment of RVF. This study aimed to explore the feasibility of an RVF animal model by magnetic compression and compare it with the traditional modeling method. Thirty-two female Japanese white rabbits were randomly divided into four groups: A, B, C, and D, based on how the rectovaginal septum was treated. The operation time, intraoperative blood loss, and model success rate of each group were determined. The experimental animals were euthanized 2 weeks after the operation. Their rectovaginal septum specimens were obtained. RVF was observed by the naked eye. The fistula size was measured. Histological changes of fistula were observed by hematoxylin and eosin and Masson staining. All rabbits completed the RVF model and survived 2 weeks after the operation. Groups A and B had no bleeding, while groups C and D had < 0.5 mL of bleeding. The magnet detached in 4-6 days in group A, while it remained in place for 2 weeks after surgery in group B. Only one group D rabbit had a plastic hose for 2 weeks after surgery. The RVFs of groups A and C healed by themselves. In group B, the fistula was well formed. In group D, fistula healing was observed in three animals and the diameter of the fistulas was only 2.82-4.64 mm in the other four animals. Groups B and D had a scar on the inner surface of fistulas. Our study shows that the magnetic compression technique based on the T-shaped magnet is a highly useful method to establishing a continuous and stable RVF model in rabbits.

Rectovaginal fistula during treatment with axitinib in a patient with renal cell carcinoma: a case report and review of the literature.

Renal cell carcinoma (RCC) is one of the most frequent malignancies of the adults. Its incidence has been increasing steadily by 2-4% each year. Up to 30% of patients present with metastases at diagnosis. It is a highly vascularized cancer because of the hypoxia-induced factor stabilization as a consequence of von Hippel-Lindau inactivation. Hypoxia-induced factor accumulation leads to transactivation of molecules involved in angiogenesis including vascular endothelial growth factor (VEGF) and platelet-derived growth factor. Sunitinib is an oral tyrosine kinase inhibitor that interacts with several angiogenesis receptors including platelet-derived growth factor receptors and VEGF receptors, and is approved for the first-line treatment in metastatic RCC. In terms of tolerability, patients treated with sunitinib showed a higher incidence of diarrhea, vomiting, hypertension, hand-foot syndrome, and neutropenia, a safety profile consistent with what had been observed in earlier phase studies. Axitnib is a potent and selective tyrosine kinase inhibitor of VEGF receptors 1, 2, and 3, and is approved in the second-line setting for patients with metastatic RCC. The tolerability profile of axitinib is favorable. The most commonly reported treatment-related adverse events are diarrhea, hypertension, fatigue, nausea, and dysphonia. Bowel toxicity, especially pneumatosis intestinalis and bowel perforation, is very uncommon. In particular, the incidence of intestinal perforation or fistulae is not well known for sunitinib or axitinib. Here, for the first time, we report the incidence of rectovaginal fistula in a 57-year-old White woman, with RCC, following treatment with sunitinib and axitinib.

MRI evaluation of anal and perianal diseases.

Anal and perianal region is a commonly affected area in the course of several inflammatory, infectious, and neoplastic diseases. Several imaging modalities may be used in imaging evaluation of this area and magnetic resonance imaging (MRI) emerges as the imaging modality of choice due to its superb soft tissue resolution. MRI is not only useful for initial detection of anal/perianal pathologies but also in the follow-up of these disorders. In this article, we aimed to illustrate MRI findings of several diseases affecting this area including perianal fistula as well as anal fissure, hypertrophic myopathy of internal anal sphincter, hidradenitis suppurativa, pilonidal sinus, rectovaginal/anovaginal fistula and anal canal carcinoma. We think that this article will serve to familiarize the imaging specialists to the MRI findings of these diseases.

Rectovaginal fistula following surgery for deep infiltrating endometriosis: Does lesion size matter?

Objective This study was performed to identify risk factors for postoperative rectovaginal fistula (PRF) in patients with deep infiltrating endometriosis (DIE). Methods Data were retrospectively obtained from the medical records of 104 patients with DIE, and statistical analysis was used to detect risk factors for PRF. Results Five of 104 (4.8%) patients developed PRF from 5 to 16 days postoperatively. The operative procedures included 84 (80.8%) superficial excisions, 6 (5.8%) full-thickness disc excisions, and 14 (13.5%) bowel resections. Most lesions were located in the cul-de-sac, and the mean lesion size was 2.6 cm (range, 0.5-7.0 cm). The univariate analysis showed that lesion location, larger lesion size, and surgical technique were statistically significant risk factors for PRF. Conclusion Surgical procedures should be very carefully executed in patients with DIE lesions of ≥4 cm.

The use of viable cryopreserved placental tissue in the management of a chronic rectovaginal fistula.

We present a case of a chronic recurrent rectovaginal fistula that initially arose from complications of haemorrhoid surgery and had failed multiple prior surgical repairs. The fistula was successfully managed using viable cryopreserved placental tissue.

Transvaginal Repair of Complex Rectovaginal Fistulas Using the Porcine Urinary Bladder Matrix as an Augmenting Graft.

BACKGROUND: After the US Food and Drug Administration issued a safety warning concerning vaginal mesh implants in 2008, their use in correction of pelvic floor defects have decreased in the United States (http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm479732.htm). However, we are still treating patients who have had complications associated with their use, rectovaginal fistulas (RVFs) being one of them. Rectovaginal fistulas are considered complex if greater than 2.5 cm, recurrent, associated with inflammatory bowel disease, or if they are proximal in location. Various surgical techniques have been described for treating RVFs. Interposition grafts such as Martius, gracilis, omental J flaps, and rectus abdominis flaps have been used extensively in correcting RVFs (Am J Gastroenterol 2014;109(8):1141-1157). However, these techniques may increase morbidity or have poor cosmesis. Pelvic surgeons have chronicled the use of biologic grafts for fistula repair. Of the various biologic grafts in use, there have been no reports describing the use of porcine urinary bladder matrix (UBM) for fistula repair. We report on 2 cases of large, complex RVFs secondary to mesh erosion, which were effectively treated with transvaginal repair using the UBM. CASES: An 80-year-old woman was referred by the colorectal service to our urogynecology service with complaints of rectal bleeding and vaginal spotting secondary to mesh erosion. Surgical history included hysterectomy with mesh augmented posterior repair with synthetic midurethral sling placement in 2002. Examination revealed a 3-cm mesh exposure located in the middle third of the posterior vaginal wall. On rectovaginal examination, a 3-cm full-thickness RVF with through-and-through mesh erosion was noted between the rectum and vagina.A 65-year-old woman presented to our service with complaints of passage of fecal material through the vagina. Surgical history was significant for hysterectomy in 1988 and prolapse repair with anterior and posterior vaginal mesh in 2009. Subsequently in 2011, she had part of the mesh removed because of exposure. Vaginal examination revealed mesh exposure at the right sulcus of the anterior wall consistent with evidence of prior sling and another mesh exposure on the posterior vaginal wall. Rectovaginal examination revealed palpable mesh in the rectovaginal septum with a 3-cm large and complex fistula. Both of our patients underwent transvaginal excision of mesh, RVF repair, and posterior repair with augmentation with UBM. At 6- and 10-month follow-up, they reported complete resolution of their symptoms with no fistula noted on physical examination. CONCLUSIONS: Typically, traditional repair with use of muscular advancement flaps is performed for complex RVF closures. Recently, however, various biologic agents have been successfully used to augment RVF repair. In our cases, the use of UBM led to successful follow-up at 6 to 8 months. Despite existing literature, there remains a void in the depth of knowledge regarding the UBM grafts. Larger studies utilizing it for repair of RVFs are warranted to further understand the success and effectiveness of the UBM grafts for RVF repair.

Stable gastric pentadecapeptide BPC 157 heals rectovaginal fistula in rats.

AIM: Rectovaginal fistula is a devastating condition providing more than 99% of patients for surgical treatment. We hypothesized that rectovaginal fistula may be healed by therapy with stable gastric pentadecapeptide BPC 157, in consistence with its initial clinical application and effect on external fistulas. MAIN METHODS: BPC 157 (10µg/kg or 10ng/kg) was given perorally, in drinking water (0.16µg/ml or 0.16ng/ml, 12ml/rat/day) till sacrifice, or alternatively, intraperitoneally, first application at 30min after surgery, last at 24h before sacrifice. Controls simultaneously received an equivolume of saline (5.0ml/kg ip) or water only (12ml/rat/day). The assessment (i.e., rectal and vaginal defect, fistula leakage, defecation through the fistula, adhesions and intestinal obstruction as healing processes) was at day 1, 3, 5, 7, 10, 14 and 21. KEY FINDINGS: Regularly, rectovaginal fistulas exhibited poor healing, with both of the defects persisting, continuous fistula leakage, defecation through the fistula, advanced adhesion formation and intestinal obstruction. By contrast, BPC 157 given perorally or intraperitoneally, in µg- and ng-regimens rapidly improved the whole presentation, with both rectal and vaginal defects simultaneously ameliorated and eventually healed. The maximal instilled volume was continuously raised till the values of healthy rats were achieved, there were no signs of defecation through the fistula. A counteraction of advanced adhesion formation and intestinal obstruction was achieved. Microscopic improvement was along with macroscopic findings. SIGNIFICANCE: BPC 157 effects appear to be suited to induce a full healing of rectovaginal fistulas in rats.

Is biological mesh interposition a valid option for complex or recurrent rectovaginal fistula?

AIM: Many surgical techniques are available for the treatment of rectovaginal fistula (RVF). There is hitherto little information on its treatment by biological mesh interposition. The aim of the present study was to analyse our results of RVF treatment using biological mesh interposition. METHOD: Patients with RVF undergoing biological mesh interposition were identified. Success was defined by the absence of a diverting stoma and/or any vaginal discharge of faeces, flatus or mucous discharge. RESULTS: Ten women [median age 39 (24.5-65) years] were included. Nine (90%) had recurrent RVF, and the median number of previous attempts at closure was 2.5 (0-8). The main cause of RVF was Crohn's disease (40%). All patients had faecal diversion. No intra-operative complications occurred from mesh interposition. Seven (70%) patients developed postoperative morbidity which was major (Dindo III) in two (20%). The primary success rate was 20% (2/10) but final success rate was achieved in 70% after reoperation with other procedures at 11.1 (2.7-13.1) months of follow-up. CONCLUSION: The study has shown disappointing results with biological mesh interposition for RVF with a healing rate lower than achieved by gracilis muscle interposition.

Influence of diversion stoma on surgical outcome and recurrence rates in patients with rectovaginal fistula - A retrospective cohort study.

BACKGROUND: Rectovaginal fistula is an extremely distressing condition for the patients. There is still no generally accepted standard surgical treatment strategy. Especially the influence of diversion stoma creation on patients' outcome remains controversial. Thus, the aim of this study was to analyze the influences of diversion stoma on the outcome of patients treated because of rectovaginal fistula with special regard to perioperative complications and recurrence rates. METHODS: Between 2003 and 2013, all patients treated due to rectovaginal fistula in our institutions were retrospectively analyzed. A total of 81 procedures were performed in 62 patients. Procedures were divided into two groups depending on the presence of a diversion stoma or not (diversion stoma, n = 42 vs. no stoma, n = 39). RESULTS: The overall rate of fistula recurrence was 44% without statistical significance in-between the study groups (49 vs. 38%; p = 0.603). Diversion stoma had no influence on complication rates, wound infections or number of operative revisions. Patients treated with diversion stoma had significantly higher ASA-scores (2.6 ± 0.6 vs. 2.1 ± 0.8; p = 0.011), higher rates of malignoma (58 vs. 17%; p = 0.001) and larger sizes of fistula (1.67 ± 0.08 vs. 1.51 ± 0.46 mm; p = 0.012). The in-hospital stay was significantly longer in these patients (30 ± 66 vs. 15 ± 15 days; p = 0.023). CONCLUSIONS: Our data suggest that diversion stoma creation does not influence the outcome of patients with rectovaginal fistula with special regard to rates of fistula recurrence. On the other hand it is mainly used in complex cases of sick patients and larger fistula sizes. Prospective clinical studies need to be conducted to reinforce these findings.

[Non-surgical management of rectovaginal fistula: a case report]. / Tratamiento no quirúrgico de la fístula rectovaginal. A propósito de un caso.

BACKGROUND: The rectovaginal fistula is a rare disease whose treatment is extremely difficult. OBJECTIVE: To present the expectant management of rectovaginal fistula as an alternative to surgery for those cases in which the surgical risk is not an acceptable option. CLINICAL CASE: We report the case of a rectovaginal fistula in an 85-year-old woman with significant comorbidity that avoided the performance of any surgical technique. CONCLUSION: In patients whose surgical risk does not exceed the benefits, non-surgical management would be an option of treatment of rectovaginal fistula.

Recto-Bartholin's duct fistula: a case report.

Bartholin's duct cysts, the most common growths in the vulva, occur in the labia majora. The cyst may become infected, and an abscess may develop in the gland. Rectovaginal fistula is a rare complication and its formation is secondary to Bartholin's cyst; only 4 cases have been reported in the literature so far. In this case, the fistula was located between the rectum and a Bartholin's duct, rather than the vagina and the rectum. We present the first case of a recto-Bartholin's duct fistula, performed surgical excision and fistulectomy. Postoperative treatment with antibiotics resulted in the complete resolution of all lesions at the 3-month follow-up.

Abnormalities in "low" anorectal malformations (ARMs) and functional results resecting the distal 3 cm.

PURPOSE: "Low" anorectal malformations (ARMs) are considered minor anomalies of the distal rectum and anal-canal development. Nonetheless, the prognosis of affected patients is far from excellent, as some degree of constipation is a frequent complaint in the long-term follow-up. Constipation in "low" ARM has been reported in 42%-70% of cases. Vestibular fistulas seem to have the highest rate of constipation (not less than 61.4%). The aim of this study was to evaluate all the histological wall abnormalities of ARM with recto-perineal and recto-vestibular fistulas in order to identify features that could explain the bowel dysfunctions. Moreover, the resection of distal perineal and vestibular fistulas (last 3 cm) allowed evaluating functional results in "low" ARM series with extensive fistula resection. METHODS: One hundred four specimens were collected from 52 patients (32 recto-perineal and 20 recto-vestibular fistulas) during the posterior sagittal anorectoplasty (PSARP). The distal 3 cm of aberrant anorectal canals (fistulas) was systematically resected and divided longitudinally. One portion was fixed for immuno-histochemical stainings (PGP 9.5, S-100, NSE), H&E, and tricromic stainings. The frozen sections of the second portion were incubated for enzyme histochemical stainings (AChE, etc.). The follow-up of 42 of 52 ARM was postoperatively evaluated at 3-8 years of age, and the assessment of the outcome after PSARP repair was in line with Krickenbeck's 2005 meeting parameters. RESULTS: Muscle coat was abnormal in all cases (100%), showing aspect and absence of organization into the circular and longitudinal layers. The connective tissue was found to be irregular and abnormally represented in 100% of cases. Abnormal vascularization was detected in 5 cases (9.6%). All vestibular (100%) and 71.8% of perineal fistulas showed different degrees of enteric nervous system (ENS) anomalies. In the series of 42 patients followed up at least after 3 years of age, 40 cases (95.2%) showed postoperative good continence without use of laxatives (according to Krickenbeck's 2005 criteria). CONCLUSION: Every wall component of the distal rectum can be affected by different structural abnormalities in "low" ARMs. Pediatric surgeons should take into consideration the implications of these structural abnormalities during radical treatment. The resection of a significant portion of the distal fistula seems to permit better functional results.

Perineal choristoma and atresia ani in 2 female Holstein Friesian calves.

Atresia ani, a congenital anomaly of the anus, can be associated with other types of malformation. Two female Holstein Friesian calves had imperforate anus, rectovaginal fistula, and perineal choristomas. In one case, the choristoma was composed of mature adipose and fibrous tissue with nephrogenic rests. In the other calf, the choristoma consisted of fragments of trabecular bone coated by cartilage and containing marrow, mixed with mature adipose and fibrous tissue, striated muscle fibers, nerves, and vessels. This combination of malformations resembles the association of anorectal malformations and perineal masses in children.

Perineal canal: a special entity of anorectal malformations in Vietnam.

PURPOSE: We report our clinical experience with the perineal canal and suggest the management. MATERIALS AND METHODS: Retrospective chart review of patients with perineal canal were classified by lesion characteristics into Group I: active perineal inflammation, Group II: vulvar excoriation and Group III: no active inflammation. Group III patients underwent primary surgical repair. Group I and II patients underwent repair after medical management. The fistula was repaired by the modified Tsuchida's technique consisting of an anterior anopullthrough and excision of the fistula tract (reverse order). RESULTS: Between September 1999 and August 2003, we treated 120 cases of perineal canal. Group I, II and III consisted of 74, 12 and 34 patients, respectively. In two patients of Group I (2.7%), the fistula tract spontaneously closed. The remaining 118 patients were surgically treated with the modified Tsuchida's technique. Recurrences were similar between patients treated with colostomy (1/28 or 3.6%) versus without colostomy (3/90 or 3.0%), as well as between patients initially treated with primary repair (3/102 or 2.9%) versus patients undergoing reoperation with redo repair (1/16 or 6.25%). CONCLUSIONS: With proper initial medical treatment, the perineal canal could be repaired successfully in one stage with the modified Tsuchida's technique.

Martius advancement flap for low rectovaginal fistula: short- and long-term results.

AIM: Many surgical approaches have been described for the treatment of low rectovaginal fistulae (LRVF); however, all are associated with a high recurrence rate and a poor function. The Martius flap technique was first described in 1928 and has since been modified for the treatment of LRVF. The aims of this study were to evaluate the short- and long-term results of the Martius flap procedure. METHOD: Twenty patients who underwent the Martius flap procedure between 2000 and 2010 were retrospectively included. Operative results and morbidity were evaluated. Quality of life (SF-12 score), quality of sexual life [Female Sexual Function Index (FSFI) score] and anal continence (Wexner score) were determined. RESULTS: Crohn's disease was the predominant aetiology (n = 8, 40%). The Martius flap was mostly harvested from the left side (n = 14, 66.7%). The morbidity rate was 15% (n = 3), and the mean hospital stay was 7.7 ± 3.7 days. At a mean follow up of 35 months, the success rate was 65%. Seven patients still had an LRVF: in patients with Crohn's disease the success rate was 50% (4/8). Fifteen patients (75%) answered the three questionnaires. Quality of life score was in the normal range: physical component summary score (PCS: 46.7 ± 9) and mental component summary score (MCS: 44.7 ± 11.3). The median (range) FSFI score was 5 (2-31.7). Eight patients (53%) deemed cured suffered no incontinence. The Wexner score was significantly higher in the presence of a persisting LRVF (2.6 ± 5.5 vs 13.4 ± 3.78) (P = 0.0018). Use of a right-sided flap was associated with a higher success rate (P = 0.0442). CONCLUSION: The Martius flap procedure for LRVF, had a success rate of about 60% and a low morbidity.